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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 577005638
Report Date: 01/19/2024
Date Signed: 01/19/2024 05:21:49 PM


Document Has Been Signed on 01/19/2024 05:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:ELDERVILLAFACILITY NUMBER:
577005638
ADMINISTRATOR:PARAMJIT SINGH SANDHUFACILITY TYPE:
740
ADDRESS:1301 HOMEWOOD DRIVETELEPHONE:
(530) 329-3834
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:6CENSUS: 6DATE:
01/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Singh Sandu Paramjit, AdministratorTIME COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection and found the facility to be clean and at a comfortable temperature. There were (2) two residents receiving hospice services and (4) four other residents receiving varying levels of care. All residents were clean, comfortable and well-groomed.

At the time of visit several residents were in the living room watching television. One resident went and got their accordion and played for the group.

LPA reviewed records, conducted interviews and made observations.

No deficiencies were found at the time of inspection.
No citations issued.

Exit interview conducted with Licensee.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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